Tilos TimTem team to experiment with tele-sonography for remote diagnosis

Tilos 24 September 2000For Professor Enrico Cavina from the Department of Surgery at Pisa University the "Tilos Medicine & Tele-medicine" project, better known as TimTem, has grown into a difficult but dearly loved spiritual child. Due to insuperable human factors, the decision to build a permanent Telemedicine Station on the Greek Dodecanesum island of Tilos remained a dream so far. After a series of discouraging experiences, the Pisa team slowly started to look at Tilos as a "continuously interesting laboratory on the field but nothing more". Yet, a recent tele-sonography initiative, set up between Tilos and the Pisa University Hospital, demonstrates that something still is cooking in this laboratory. The name of the recipe is tele-consultation.


In the period between July 24th and August 8th 2000, the TimTem team organised an experiment to perform thirty ultrasound examinations at the clinical ambulatory on Tilos. The images were transmitted in real time or as static data for remote diagnosis of pathologies at the Surgery Department of Pisa University. The patients were examined without planning during their routine visit to the clinical centre by local medical and paramedical staff with no expertise in ultrasound diagnosis. Guided via videoconferencing, the local team performed the scans for specific organ studies under the supervision of an expert physician who was allowed not to interfere but only to confirm the diagnosis performed at distance.

The equipment consisted of an Ultrasound System SonoSite 180 device with a convex 3.5-5 MHz Probe; of twin computers, one at each site; two standard computers for tele-conferencing in Netmeeting; the German software InViVo TeleConsult; and an ISDN line. The transmission from Tilos was established by an expert in telematics and software. The ultrasound examinations have been carried out with standard scans that are generally accepted in routine medical practice and in emergency cases. The aims of the tele-sonography experiment were to evaluate the use of a dedicated ultrasound software for consultation, handled by a staff with no ultrasound expertise, and to assess the performance of connection systems, such as ISDN lines and the Internet in ultrasound tele-consultations of this type.

At the same time, the Pisa team also wanted to measure the responses' time and the clinical impact of tele-consultation in critical emergency cases. The result was a 100 percent diagnosis conformity of both positive and negative examinations between the tele-sonography team and the supervising expert on Tilos. The operational time of the entire system was about 5,43 minutes on average for the direct TeleConsult connection and some 12,30 minutes for the videoconference. The TeleConsult connection included static images and dynamic loops for the transmission of organ scan sequences with an average transmission time of 5 minutes for a 2 Megabyte file. The average time for 1 diagnosis procedure after the arrival of the images was 9,53 minutes, taking into account 2 cases of colour images requiring a longer time, and the mean time from studying the data to the diagnosis conclusion was 11,06 minutes.

It was found that the remote interpretation of transmitted images requires a basic medical knowledge and an elementary ultrasound diagnosis training to perform scans. Professor Cavina stated in his report the need for a qualified expert staff, both at the remote and local site; conformity of the ISDN lines to ECC rules; and improvement of the TeleConsult software with a possibility to use a professional Webcam for the remote control of untrained personnel. If these conditions are fulfilled, tele-sonography could become a useful tool for routine and emergency remote diagnoses, third level consults in peripheral centres, and training in remote areas.

As such, the staff responsible for the ultrasound study can be divided into three types of personnel: those performing the ultrasound scans, those who transmit the images and those interpreting the transmitted images. In order to make a precise diagnosis in relation to the patient's clinical picture, it is necessary to standardise the diagnostic protocols as well as the acquisition procedure for the scans, according to Professor Cavina. The local staff in the remote areas must be able to interpret the images and also to get the scans in agreement with the reference centre. Therefore, the need for some basic informatics knowledge is indispensable. "This is the reason why a one-month training, at least, is necessary for the technical informatics side and for the performance of an ultrasound exam with essential elements for the organs' assessment", Professor Cavina stated.

We invite you to read the VMW August 2000 article Reactivating Telemedicine on Tilos leaves TimTem balancing between scepticism and hope to learn more about the TimTem project.

Leslie Versweyveld

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